Basics
Description
- Attention-deficit/hyperactivity disorder (ADHD) is a chronic condition that is characterized by a pattern of developmentally inappropriate behaviors of inattention and/or hyperactivity/impulsivity.
- DSM-5 criteria for diagnosis:
- At least 6 of 9 behaviors in inattention and/or 6 of 9 hyperactivity/impulsivity behaviors and
- Maladaptive behaviors persisting for at least 6 months and
- Impairment from symptoms present in 2 or more major settings (home, school, day care, after-school activities) and
- Some symptoms existed before age 12 years.
- It can be classified into 3 subtypes:
- Hyperactive/impulsive
- Inattentive
- Combined type
- Symptoms cannot be better explained by another mental health disorder. Autism spectrum disorder is no longer an exclusion criteria.
Epidemiology
- 2:1 males-to-female ratio
- 3-10% prevalence of school-age children
- Females more likely to have inattentive type
Risk Factors
Genetics
- Risk of ADHD in 1st-degree relatives is ~25%.
- Concordance in monozygotic twins: 59-81%; dizygotic twins: 33%
Commonly Associated Conditions
- Learning disorders
- Language disorders
- Anxiety disorder
- Mood disorders
- Sleep disorders
- Tic disorder (may affect treatment decisions)
- Oppositional defiant disorder and conduct disorder
- Poor social skills
Diagnosis
- Primary care clinicians should consider an extended visit to evaluate any child, age 4-18 years, presenting with behavioral and/or academic problems related to ADHD symptoms.
- To make the diagnosis, the clinician should ensure DSM-5 criteria are met and document impairments in >1 major setting (e.g., home, school, day care). Information should be gathered from more than one reporter, when possible (e.g., caregivers and teachers).
- Comorbid conditions may prompt a referral to a subspecialist.
- In general, the diagnosis does not require any specific psychological test, cardiac test, laboratory test, or referral.
- Watchful waiting is not recommended, as evidence-based treatments can make significant improvements even at a young age.
History
- A detailed history of the child's behavior at home, school, and with peers
- Onset and duration of noted behaviors-sudden onset should prompt consideration of other conditions (mood disorder, trauma, abuse, substance use, etc.).
- Timing of behaviors with respect to developmentally appropriate expectations placed on the child
- Frequent or excessive need of supervision and redirection in age-appropriate common tasks and routines
- Not following rules/requests-oppositional and/or "forgetful"Ł (getting lost or side-tracked)
- Academic progress with particular attention to academic problems with specific subjects, and behaviors during specific subjects
- Disruption of peer relationships
- Developmental history (developmental delay is not characteristic of ADHD)
- Sleep history-adequate length, hygiene
- Participation in age-appropriate organized activities (e.g., scouts, camp, team sports)
- Family history of dropping out of school, ADHD, or learning disorders
- Family history of early cardiac disease including arrhythmias, hypertrophic cardiomyopathy, sudden cardiac death or unexpected death in children or young adults
- Social history: those who live with patient, recent family discord, separation, recent death in the family, recent change in schools
- Past medical history and medication history
- Adverse pregnancy or birth history
Alert
Ability to concentrate for hours on video games is not reassuring but commonly reported. á
Physical Exam
- Comprehensive physical and neurologic examination with attention to specific systems based on the history
- Vital signs: weight, height, pulse, BP, visual and hearing acuity
- Note any dysmorphology.
Diagnostic Tests & Interpretation
- Validated rating scales of behavior help the clinician review DSM-5 criteria. After the initial concern is raised, these can be distributed, collected, and reviewed prior to a scheduled evaluation.
- Connor Rating Scales-Revised, Vanderbilt ADHD Rating Scales, SNAP, ADHD RS
- Ideally, collect rating scales from parents and teachers.
- Some assess only for ADHD; others include assessment of comorbidities such as anxiety, oppositional defiant disorder, and depression (Vanderbilt).
- Most clinicians choose a single tool and gain familiarity with it.
- Most scales are useful to measure change with treatment.
- Some are proprietary (Conner), and some are freely distributed (Vanderbilt).
- IQ and achievement testing
- Not required but should be guided by specific concerns for disabilities
- An evaluation for an Individual Educational Program (IEP) or 504 plan may be obtained following parental written request to the child's school.
Lab
Not required except as guided by history and physical. Screening ECGs are not recommended or considered cost-effective. á
Differential Diagnosis
- Developmental
- Learning disabilities
- Intellectual disability
- Autism spectrum disorder
- Language or speech disorder
- Psychiatric
- Anxiety disorders
- Depression
- Obsessive-compulsive disorder
- Oppositional defiant disorder or conduct disorder
- Adjustment disorder
- Medical
- Genetic disorder
- Sleep disorder
- Sensory impairment (vision, hearing)
- Medication side effects
- Toxins (lead)
- Iron deficiency anemia
- Postconcussion syndrome
- Educational
- Inappropriate school environment
- Developmentally inappropriate expectations
- Social
- Disorganized/chaotic family environment
- Child abuse and neglect or sexual abuse
- Psychosocial stressors
Treatment
General Measures
- Treat ADHD as a chronic disease and use the medical home model. Partner and discuss treatment options with families. Include the school when possible.
- The family and patient choose target goals and actively participate in measuring/monitoring achievement of these goals.
- 3 treatment modalities:
- Behavior therapy (evidence based)
- Educational support
- Medication
Nonpharmacologic
- Children 4-5 years: behavior therapy
- Reduces core symptoms of ADHD in multiple settings. Different from interpersonal talk/play therapy, which has not been efficacious in treatment. Parent education, parent training programs, and behavior therapies usually have a planned number of weeks (10-16 weeks). Their focus is increasing positive behavior through rewards and extinguishing negative behavior through ignoring and effective discipline.
- Cognitive behavioral therapy can be helpful for older children and adults.
- Educational support options:
- Request a 504 Plan through patient's school to evaluate for possible accommodations (different from an IEP).
- Small teacher-to-student ratio is ideal.
- Good communication between school and home (e.g., a daily behavior report card)
- Homework log monitored by teacher and parent
- Psychological support may be helpful for:
- Patient who has poor peer relations, such as peer groups or social training groups
- Patient with a comorbidity
- Commonly, families have difficulty with parenting a child with ADHD.
Medication
Consider family preferences, other family member's reaction to specific medications, duration of coverage (shorter school day in younger child), ability to swallow pills, and concern for divergence (or abuse). á
First Line
- Stimulants: FDA-approved. All are either methylphenidate or amphetamine-class derivatives.
- Efficacy: extensive evidence supporting efficacy and safety. 80% of children with ADHD show significant improvement.
- Pharmacokinetics: Individual response is highly variable. Effectiveness and side effects can be seen within hours of starting medication. Duration varies by preparation. Younger children may metabolize stimulants slowly, giving a longer duration than expected for immediate-release preparations. Does not "build up"Ł in the system, so no known permanent effects. Daily dosing therefore necessary for symptom relief
- Dose: Weight-based dosing is not appropriate due differences in metabolism and idiosyncratic responses. Start with smallest dose and titrate up in single-dose increments weekly as needed. Base titrations on changes in rating scales and achievement toward target goals, weighing improvements against side effects. Start with short-acting medication in children younger than 7 years. For some younger children, this may provide a sufficient duration of therapy for school. Consider long-acting/extended-release in older children. Start medication when the parents are available to watch for side effects and duration of action (typically over a weekend). Follow closely with the parents; ask them to get feedback from school on a weekly basis until dose is properly adjusted. This process may take 1-2 months to be completed. If at highest dose and still not having good effect, or having significant side effects at a lower dose, switch to the lowest dose of the other class of stimulants and repeat the titration process.
- Side effects: Side effects last less than 24 hours. Families should know that any unacceptable side effects will abate if the medication is stopped. Most side effects can be managed expectantly.
- Decreased appetite is common, although sustained weight loss is not.
- Abdominal pain, tics, headache, difficulty falling asleep, and jitteriness
- Difficulty shifting attention, overfocus (the "zombie effect"Ł) is from too high of a dose.
- Severe movement disorders, obsessive-compulsive thoughts, or psychotic symptoms are rare and cease when medication is stopped.
- Growth velocity may slow. Final adult height is minimally decreased, if at all affected.
- Contraindications: glaucoma, symptomatic cardiovascular disease (except with guidance by cardiology), hyperthyroidism, hypertension
Second Line
- Atomoxetine: selective norepinephrine uptake inhibitor. Once-a-day or b.i.d. dosing. Must be taken daily for 4 weeks before effects are at maximum. Similar side-effect profile as stimulants but with increased chance of suicidal thinking. Less evidence for use and less efficacious than stimulants. Start with 0.5 mg/kg/24 h for 1 week, and if no side effects (often GI upset), increase to 1.2 mg/kg/24 h, max 1.4 mg/kg/24 h or 100 mg/24 h if >70 kg.
- Adjuvants: extended-release ╬▒-adrenergic agonists (clonidine, guanfacine). Must take daily. Commonly causes sedation that may improve with time
Issues for Referral
- When comorbidities are suspected, or when contra-indications for treatment are present
- If patient is not responding to titration attempts of both stimulant classes
- If the patient is having difficulty tolerating different stimulants, or having unexpected or severe side effects
Ongoing Care
Follow-up Recommendations
- Initially, follow-up by phone may be every 1-2 weeks until proper dosing is achieved. Follow up in clinic in 1 month. After successful titration, patients should be seen every 3-6 months specifically for ADHD visits.
- Consider mailing refills once titrated to prevent burden on families who'd otherwise pick up the paper prescription.
- Monitor weight, height, BP, and heart rate.
- Weight loss is not usually sustained.
- Encourage meals when patient is hungry, perhaps later than family's usual dinner.
- Assess for change in growth velocity.
- Assess family and peer relationship.
- Assess school performance.
- Assess for ongoing need for medication.
Additional Reading
- Collett áBR, Ohan áJL, Myers áKM. Ten-year review of rating scales. V: scales assessing attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2003;42(9):1015-1037. á[View Abstract]
- A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073-1086. á[View Abstract]
- Graham áJ, Banaschewski áT, Buitelaar áJ, European Guidelines Group. European guidelines on managing adverse effects of medication for ADHD. Eur Child Adolesc Psychiatry. 2011;20(1):17-37. á[View Abstract]
- Perrin áJM, Friedman áRA, Knilans áTK, et al. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics. 2008;122(2):451-453.
- Weber áW, Newmark áS. Complementary and alternative medical therapies for attention-deficit/hyperactivity disorder and autism. Pediatr Clin North Am. 2007;54(6):983-1006.
- Wolraich áM, Brown áL, Brown áRT, et al. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022. á[View Abstract]
Codes
ICD09
- 314.01 Attention deficit disorder with hyperactivity
ICD10
- F90.9 Attention-deficit hyperactivity disorder, unspecified type
- F90.1 Attn-defct hyperactivity disorder, predom hyperactive type
- F90.0 Attn-defct hyperactivity disorder, predom inattentive type
- F90.2 Attention-deficit hyperactivity disorder, combined type
- F90.8 Attention-deficit hyperactivity disorder, other type
SNOMED
- 406506008 Attention deficit hyperactivity disorder (disorder)
- 7461003 Attention deficit hyperactivity disorder, predominantly hyperactive impulsive type
- 702815001 Attention deficit hyperactivity disorder, inattentive presentation (restrictive) (disorder)
- 31177006 Attention deficit hyperactivity disorder, combined type (disorder)
- 192127007 child attention deficit disorder (disorder)
FAQ
- Q: What is the role of diet or complementary and alternative medical (CAM) therapies?
- A: Although in the past, it has been thought that certain foods and additives caused ADHD, there are no studies that show changes in diet to be of benefit. Frequently, families will want to explore the use of CAM therapies either in conjunction with or instead of treatment with stimulant medication. If safety can be assured, it may be reasonable for patients to try for a finite period of time if it ultimately helps the patient. If CAM therapy fails, the parents may be more willing to try stimulant medication.
- Q: Is medication needed every day?
- A: This depends on the needs of the patient and type of medication. Some patients need medication daily in order to function successfully with peers or in structured environments, like team sports or weekend schools. Other patients who need help mainly with focusing attention do well with medication only during learning periods (school days). Some patients will not need medication during the summer holiday or during school breaks.
- Q: How long will my child be on medication?
- A: A large percentage of children with ADHD will continue to have symptoms as adults. Although every patient is different, some patients may need to continue medication through formal learning (high school and college). During this time, they should be able to learn coping strategies to minimize the effects of their symptoms. If treatment goals are being met, it is reasonable to have a trial off medications to see if performance off medications can be sustained (sometimes called a drug holiday).
- Q: Are there support groups available?
- A: An organization that is widely recognized as an advocacy and support group for families is Children and Adults with Attention Deficit/Hyperactivity Disorder (www.chadd.org). Use discretion when using online resources; there are many online Web sites that are sponsored by pharmaceutical companies and others that encourage alternatives to medication and actively discourage use of currently recommended treatments.